Assessment Flashcards
S3
Aka ventricular gallop
Not normally heard in people with normal heart sounds.
Can be present in healthy children and young adults
When heard in older adults, is often associated with moderate to severe heart failure
Is a soft, low pitched heart sound, when present considered to be “lub-DUB-da”
Often associated with abnormal filling pressures in the atria secondary to heart failure
page 341
Romberg test
Measures your sense of balance
Ptosis
Droopy eyelid
Can be just a little or can droop so much that it covers the pupil
Stridor
Brassy crowing sound often heard without a stethoscope
Caused by narrowing, swelling or obstruction of the upper airway and may indicate the pt has an airway obstruction in the neck or upper part of the chest
Tricuspid valve
Right atrioventricular valve.
Separates the atrium and ventricle on the right side of the heart.
Hearing Acuity
How well/clearly a pt can hear
Tinnitus
Ringing in the ears
Orthostatic vital signs
aka Tilt test
Measures fluid loss/dehydration
Measures BP and pulse rate for changes in supine, sitting and standing position
Considered positive when the pt’s systolic blood pressure decreases up to 20 mmHg, diastolic pressure increases more than 10 mmHg (a narrowing pulse pressure) and pulse rate increases by 20 beats
Take vitals at 1 min intervals between moving a pt to a new position.
Make sure not to take vitals right after moving the pt. You need to wait 2-3 minutes for the pt to be in the new position at least.
page 571
Acuity
Sudden onset Critical Acuit MI Acuit illness Acuit episode
Confabulation
The creation of false memories
Person have no recognition that the information being relayed is fabricated
Going from pounds to kilograms
Number deviled by 2 minus 10%
150 divided by 2 minus 10%
180 deviled by 2 minus 10%
Rhonchi
aka Congested breath sounds
Lower pitch and a rattling quality
May indicate the presence of mucus in the lungs
PERRLA
Pupils
Equal
Round
Reactive to
Light and
Accommodations
S4
Aka atrial gallop
Not normally heard. If heard, almost always abnormal.
Medium pitched heart sound that occurs immediately before the normal S1 sound (like a flam). “bla-lub-DUB”
If present represents either decreased stretching (compliance) of the left ventricle or increased pressure in the atria.
Babinski reflex
Positive (abnormal) younger than 2 - when pt toes curl down
Negative (normal) under 2 - pt pulls away
Positive (abnormal) 2 and older when a pt’s toe(s) flex up from stimulation on the bottom of the foot
Negitive (normal) circumstances the toe(s) flex down if older than 2
Murmur
An abnormal whooshing sound heard over the heart that indicates turbulent (unsteady, violently) blood flow through the heart valves.
Orthopnea
Positional dyspnea
Clubbing
Chronic respitory disease
Chronic hypoxia
S2
Is the second heart sound described as “DUB”.
Occurs near the end of ventricular contraction (systole) when the pulmonary and aortic valves close
page 340-341
Differential diagnoses
A list of possible conditions or diseases that could be causing the symptoms. `
Wheezing
Suggests lower airway obstruction
Is a high-pitched whistling sound that is most prominent on expiration but can be heard on inspiration in sicker pts
If only present unilateral suspect aspiration of foreign body or infection
If present bilateral suspect asthma
page 565